Download Abdominal Exam for Advanced Practice

Abdominal Exam for
Advanced Practice
CESAP/PACR
2012
Outline
•
•
•
•
•
•
History
Risk
Examination
Abnormal Findings/Differential Diagnoses
Variants for Children
Variants for Elderly and Pregnancy
History
• Presenting complaint
• Area, origin, pattern, duration, onset of
symptom?
• Associated Symptoms
• Menstrual/Sexual History?
• PMH (surgical history, medications)
• Other (Nutrition, Diet, ETOH/Drugs, Stress,
Travel)
GI/GU Specific
•
•
•
•
•
•
•
Pain/Discomfort
Urinary habits
Nausea/vomiting/diarrhoea
Bleeding
Anorexia
Gyn/Ob history
What else???????
Bowel habits
– http://www.youtube.com/watch?v=jsVgi8hoFFc
• Ask the patient about bowel movements
– Frequency of the bowel movements
– Consistency of the bowel movements
(diarrhea vs. constipation)
– Any pain with bowel movements
– Any blood or black, tarry stool (meleana) with the bowel movement
– Ask about the color of the stools (white or gray stools can indicate
liver or gallbladder disease)
– Look for any associated signs such as jaundice
or icteric sclerae
Risk Factors
• BMI (over or under?)
• Health Behaviours (ETOH, Drugs, Crash
Diets, Medications)
• Chronic Disease
– Modifiable (change in peristalsis?)
– Non-Modifiable (medications, inactivity, family
history)
Preparing for Exam
• Stethoscope
• Full exposure to abdomen however
maintain appropriate draping
• Have patient lie supine with arms at sides,
legs slightly bent
Anatomy of the abdominal GI
tract
Landmarks
Musculature
Vasculature
Vital Organs
Kidneys
• Described as posterior organs
• The upper poles are protected by ribs
• Costovertebral angle/ Renal angle
This is the angle formed by the 12th rib &
transverse process of the upper lumber
vertebrae.
Pain in Abdominal Areas
Types of Visceral Pain
History Taking of Problems of the
Abdomen: GI Tract
• Qualify the patient’s pain
– Visceral pain: when hollow organs (stomach, colon) forcefully contract
or become distended. Solid organs (liver, spleen) can also generate this
type of pain when they swell against their capsules. Visceral pain is
usually gnawing, cramping, or aching and is often difficult to localize
(hepatitis)
– Parietal pain: when there is inflammation from the hollow or solid
organs that affect the parietal peritoneum. Parietal pain is more severe
and is usually easily localized (appendicitis)
– Referred pain: originates at different sites but shares innervation from
the same spinal level (gallbladder pain in the shoulder)
Review of Systems-Tips
• Remember these are subjective findings you ask
the patient
• Questions often pertain to symptoms but also to
common diseases related to the system you are
examining
• Start with a generic question “How is your
digestion?” or “How about your bowels?”
• The goal is to uncover problems the patient may
have overlooked.
Examination
•
•
•
•
Inspection
Auscultation
Palpation
Percussion
Examination
• Consider landmarks
• Four quadrants/ Nine
regions
• 1. Epigastric,
2.Umbilical,
3.Suprapubic,
4&5.Right and Left
hypochandriac,
• 6&7. lumbar
• 8&9. inguinal areas
Landmarks
Systemic Inspection
• Inspection should include looking for signs of chronic
disease overall:
• Nail beds/palms of hands
• Skin/hair
• mucous membranes (mouth and anus)
• eyes
Focused Inspection
• Contour of abdomen– Rounded? Protuberant? Scaphoid? Flat?
• Skin characteristics– lesions, hernia, scars, striae, tattoos,
echymosis, hair distribution
• Other
– gravid, ascites, nodules
– Aortic pulsations, peristalsis, movement, vein
visibility
Inspection
Inspection
Inspection
Palpation
• One or two handed technique.
Use finger pads not tips
• Watch facial expressions!
• Palpate in three phases: light,
deep and during respiration
– Light for tenderness.
– Deep palpation of organs and
to detect masses/tenderness.
– Palpate during respiration to
feel for “shifting” of organs
with breathing.
Palpation
• Assess organs, muscle spasms, masses, fluids
and tenderness (6 F’s)
• Check umbilical ring (round and no
abnormalities)
Palpation of Liver
Palapation of the liver should
be performed by placing your
hand on the right upper
quadrant, with index finger in
line with the costal angle. Ask
patient to breath in and push
hand inwards and upwards. A
liver edge should be felt.
Palpation of the kidneys
To examine the kidneys place
hand on right side of abdomen
below the costal margin, above
the umbilicus and the left hand
under the back below the liver.
Press firmly up with the left hand
and down with right. Repeat on
the left hand side. If enlarged the
kidney will be palpable.
Renal angle
• Percuss the renal angle with your fist with
moderate force.
Palpating the Spleen
A spleen is not palpable
unless it is enlarged. Use your
left hand under left lower rib
cage, position finger tips so
they point to axilla and press
inwards and upwards. You can
also ask the patient to take a
deep breath and feel again.
Abdominal Reflexes
•
•
•
Lightly but briskly stroke each side of the
abdomen using a key or tip of wooden
applicator (Tests T8-10 (above the umbilicus)
and T10-12 (below the umbilicus)
Note the contraction of the abdominal muscles
and the deviation of the umbilicus towards the
stimulus
If reflex diminished could be related to obesity
or pregnancy
Auscultation of
Vascular Sounds
Palpating the Aorta
Percussion
• Systematic route
• To assess size and
density of organs
• To distinguish gas,
ascites, cystic or solid
masses
• Tympany= air. Usually
high pitched/musical
• Dullness=organs or
masses. Short, highpitched with little
resonance.
Percussion of liver
•
When percussing the liver you are
measuring it’s size, start at the
right mid-clavicular line where you
will start with lung resonance and
percuss down the sound changes
to dullness. Then percuss up
starting in the mid clavicular line
level with umbulicius and note
where the sound changes.
Measure between these two
points .
Percussion of Liver
• Important to define borders, especially in
diseased patient
• Normal measurement 6-12cm in adult
• Check for nodules, tenderness,
irregularities
• Report liver size via span and extent of
projection from costal margin.
Percussion of Spleen
• Percuss for dullness as usually tympanic!
(so if hear dullness (+) finding!)
• Typically from 6th to 10th rib
• Have patient inspire while percussing….if
spleen enlarged, tympany changes to
dullness
Percussion
• Abnormal findings
Auscultation
• Use diaphragm for bowel sounds
• Use bell for vasculature sounds…bruits, friction
rubs, venous hum
• Listen for clicks/gurgles: “borborygmi”…5-35 per
minute. Usually more active after meal.
• Absence of sounds established only after 3
minutes of continuous listening.
• *Should be done prior to percussion/palpation as
bowel sounds may change with manipulation
Auscultation
• Absent bowel sounds indicate ileus
• Increased bowel sounds (including highpitched tinkling or marked borborygmi)
indicate obstruction, bleed, malabsorption,
carcinoid syndrome
Abnormal Findings/Differential
Diagnoses
• Cholecystitis….+ Murphy sign (cessation of
inspiration with palpitation of gallbladder.)
• Pancreatitis, epigastric tenderness or ectopic
pregnancy, +Cullen sign (ecchymosis around
umbilicus.)
• Alcoholic Hepatitis…palpate an enlarged liver
with marked tenderness
• Dysphagia....complaint of pain in the throat or
chest region indicates oesophageal disorder.
Abnormal Findings/Differential
Diagnoses
• Costovertebral angles for kidney tenderness…indicates
renal disease/pyleonephritis
• Suprapubic tenderness typical with cystitis
• Ascities…percuss for shifting dullness and/or test for
fluid wave (often found too late)
• Appendicitis….check for rebound tenderness (Romberg
sign), guarding, McBurney’s sign, Psoas sign, Obturator
sign
Exam of the Anus, Rectum
and Prostate
Risk Factors
• Health Behaviours (ETOH, Drugs, Crash
Diets, Medications)
• Chronic Disease
– Modifiable (Drugs, depression, stress,
inactivity)
– Non-Modifiable (medications, neurologic
disorders, family history)
Anus, Rectum and Prostate
• Terminal portions of GI tract
• Sphincter/ring muscles internally and externally
in anus
• Mucosal tissue
• Anus controls excretion of faeces, rectum stores
it
• Rectum continuous with sigmoid colon
• Prostate located at base of bladder/surrounds
the urethra. Composed of muscular and
glandular tissues. Responsible for secretion
Review History
• Change in patterns, consistency, colour,
odour, flatus, pain, nausea, fever,
distension, change in urinary function,
hesitancy, nocuturia, dysuria,
dripping/dribbling, urethral discharge?
• For exam…….consider patient
position…side lying, knee-chest,
standing…or perform during pelvic
Don’t Omit This Exam
• Due to patient discomfort, examiner
discomfort…..this exam is often omitted
inappropriately!
• Important to the overall clinical
examination of the alimentary tract, genitourinary tract and more! (back pain,
anaemia, unexplained weight loss, etc)
Exam
• Inspect for haemorrhoids, skin tags, condyloma,
lesions, fissures/fistulas….then patient needs to
bear down…look for same as well as polyps,
prolapse.
• Use clock references
• Palpation of external
• PR…go slowly and warn patient. Use lubricant.
• Palpation of internal
–
–
–
–
muscle tone/anal sphincter ring.
Should feel smooth/even pressure.
Feel post/lateral walls for nodules, masses, pain.
Test any stool retrieved for guaiac.
Exam
• Prostate exam – warn pt may feel urge to
urinate. Note size, shape, consistency.
Normal feels similar to eraser/4cm. Should
be slightly mobile and not tender! Lobes
should be symmetric
• Stimulation of prostate could cause
urethral discharge…….if so culture
sample!
Abnormal Findings/Differential
Diagnoses
• Bloody stools (bright red vs.
black)….haemorrhoids, ulcer, carcinoma.
• Steatorrhea….indicative of malabsorption
syndrome or CF
• Large, tender, purplish-blue lesions
around external sphincter……thrombosed
haemorrhoids
• Benign hypertrophy…usually boggy.
Carcinoma usually hard and nodular
Abnormal Findings
Abnormal Findings
Abnormal Findings
Abnormal Findings
Variants for Paediatrics
• In newborns- abdomen should be rounded…any
concavity or distension considered abnormal
–
–
–
–
check umbilicus….note any protrusion/hernia
Infants/children swallow more air….expect more tympany
Palpation easier if infant sucking (muscles will relax)
Liver palpable 1-2cm below costal margin, spleen usually not
palpable
– Diastasis recti- a normal finding (separation of the medial rectus
sheath…visualize vertical outpouching at the midline)
– 2 arteries/1 vein in umbilical cord
• In Toddlers- abdomen is last to “slim”…..Pot belly
common
– May be difficult to examine due to trust/ticklishness/fear
– Common to fecal matter mass (hard round balls in LLQ)
Variants for Paediatrics
• School Age Children- similar to adult exam
– Spleen enlargement common in viral illnesses
• Rectal exam not necessary on
children/infants unless problem
Variants for Elderly
• Consider positioning for patient….can they
comfortably lie supine?
• Elderly….abdominal wall is thinner so usually
easier to feel.
• Constipation a frequent complaint in elderly due
to decreased intestinal motility.
• Sphincter tone may be decreased.
• Older males typically have enlarged
prostate…should feel smooth, rubbery and
symmetric.
• Screening faecal occult, sigmoidoscopy and
colonoscopy recommended after age 50.
Variants for Pregnancy
• Decreased bowel sounds normal.
• Constipation common due to hormonal
changes.
• Linea nigra and striae normal findings.
• Top of uterus palpable at level of the
umbilicus at 20 weeks.
• Difficult to identify abdominal masses in
later stages of pregnancy
References
• Hogan-Quigley,B; Palm,M;Bickley,L (2012) Nursing
Guide to Physical Examination and History Taking.
Lippincott, Williams & Wilkins.
• Bickley,L; (2009) A Guide to Physical Examination and
History Taking (10th Ed) Lippincott, Williams & Wilkins.
• Royal College of Surgeons. http://www.edu.rcsed.ac.uk/
• Seidel, H., Ball, J., Dains, J., Benedict, G.(1995)Mosby’s
Guide to Physical Examination. (3rd Edition)
• Browes,N et al (2005) Browse’s introduction to the
symptoms and signs of surgical disease. 4th Ed. London